Laserfiche WebLink
County <br /> Safety and Buildings Division /3N rve- <br /> p 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ". . P Madison,WI 53707-7162 Sly-.�3—212 <br /> ti _. OO C <br /> Cr l -13 -.2_27 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary o2 if/ye) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. r//A/i s04) ^ d <br /> I. Application Information—Please Print All Information �C3 <br /> Property Owner's Name Parcel# 07 O,2 O A IvO/6.2 3S <br /> C A AA 0 /50,) 7?4"S 7 d o 003 45100 To.x ID:3 41340 <br /> Property Owner's Mailing/Address Property Location pc,/p2 75 C/Q-(/4/)')u5 G. i/`G/e Govt.Lot .3 <br /> City,State Zip Code Phone Number y, <br /> /. ,3 <br /> , Section <br /> /ne-01,AJ f /!')iii 553ye) (circleone) <br /> H.Type of Building(check all that apply) Lot# 1 to T y0 N; R �6 E or(�J <br /> 6 K1 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> �� Block# �— <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> 0 State Owned—Describe Use CS`M/Number /33 ❑ Village of <br /> %Town of A AK 4A-)41 <br /> V ♦7 p /s' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision 0 Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> I.Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Tao /. 6 562. s e6 S /C 7 — ?Z 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p L o ,b, <br /> New Tanks Existing Tanks v o . y <br /> at U in v, 2 iy C7 i% <br /> Septic or I1e4diri 1•an?c a 00 B .0700o / Ail / 5 e,/-- /--- <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> WADE RUFSHOLM 227691 715-349-7286 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 kII.County/Department Use Only <br /> Permit Fee Date Issu d Issuing Agent Signature <br /> Approved ❑ Disapproved $ (/z5 �Z'�2�2�❑ Owner Given Reason for Denial 11 J "' j(.C! <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> flitet1 CaA 14-Nbac C.'k /L "10 t'/ s <br /> Fvltow CU,/ Cal,cnd'y aid f-Iic-if reJ azdi L i E C E 0 V E D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 in es ioDEC 1 1 2023 <br /> Burnett County J <br /> SBD-6398(R. 11/11) Land Services Department <br />